Sexually Transmitted Infections in Latinas

Hispanic/Latina women are disproportionately affected by sexually transmitted infections (STI). It is reported that approximately 70% of chlamydial infections and 50% of gonococcal infections in women are asymptomatic (1). Since many STIs don’t show immediate or identifiable symptoms, there is often a lack of awareness about infection in Hispanic/Latina women. These infections are detected primarily through screening programs, and many Hispanic/Latina women do not have access to these types of programs. Because many Hispanic/Latina women do not have health insurance, they may not be able to seek routine gynecological visits and get screened. The vague symptoms associated with chlamydial and gonococcal PID cause 85% of all women to delay seeking medical care, thereby increasing the risk of complications like infertility and ectopic pregnancy (1). In addition, reporting of these communicable diseases is lacking due to the many barriers that Hispanic/Latina women face in the present health care system. Hence, STIs are often underreported and the rate of infection is underestimated in this group of women. It is therefore impossible to understand the magnitude of the impact of STIs on Hispanic/Latina women, but it is clear that these women, their families and communities are at a tremendous risk (2)

Why are STIs significant and what impact do they have? Women and infants disproportionately bear the long term consequences of STIs. Women infected with Neisseria gonorrhoeae or Chlamydia trachomatis can develop pelvic inflammatory disease (PID), which, in turn, may lead to reproductive morbidity such as ectopic pregnancy and tubal factor infertility. If not treated appropriately, 20% to 40% of women infected with chlamydia and 10% to 40% of women infected with gonorrhea may develop PID. For those women that develop PID, tubal scarring can lead to infertility in 20%, ectopic pregnancy in 9%, and chronic pelvic pain in 18%. Results from a randomized controlled trial of chlamydia screening in a managed care setting found that screening programs can decrease the incidence of PID by as much as 60% (1).

Not only are women at risk for developing complications from STIs, but neonates are at risk as well. For example, gonorrhea and chlamydia has been reported to cause adverse outcomes in pregnancy, including neonatal ophthalmia and, in the case of chlamydia, neonatal pneumonia (1).

Syphilis also complicates pregnancy. The infection can be transmitted to the fetus in utero. This may result in fetal death, or an infant born with physical and mental developmental disabilities. Most cases of congenital syphilis are easily preventalbe if women are screened for syphilis during their prenatal care visits, and treated early (1).

Human papillomavirus (HPV) infections are highly prevalent, especially among young sexually-active women. While the great majority of HPV infections in women resolve within one year, they are a major concern because persistent infection with specific types are causally related to cervical cancer and Pap smear abnormalities. More information about HPV and cervical cancer can be found in the "Cervical Cancer" section of this module.

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From 2002 to 2006, chlamydia rates increased in all population groups. In African Americans, rates increased by 17.2%; rates increased by 23.7% among American Indian/Alaska Natives; 12.7% among Hispanics; and 20.6% among whites. All racial and ethnic groups (except Asian/Pacific Islanders) reported increases in chlamydia rates from 2005 to 2006. In 2006, the chlamydia rate among Hispanics overall was 477 cases per 100,000 population - approximately 3 times higher than the rate for non-Hispanic whites (see Fig. 1). However, the rate of chlamydia infections was nearly 4 times higher in Hispanic/

Between 2002 to 2006, gonorrhea rates increased by 22.9% in American Indian/Alaskan Natives, 17.7% among non-Hispanic whites, and 11.8% among Hispanics. All racial and ethnic groups except Asian/Pacific Islanders reported slight increase in gonorrhea rates from 2005 to 2006. In 2006, the gonorrhea rate among Hispanics was 77.4 cases per 100,000 population which was 2 times higher than the rate for non-Hispanic whites (see Fig. 2). Gonorrhea infections

Fig. 2. Gonorrhea - Rates by Race/Ethnicity and Sex: U.S., 2006
Fig-2 GC Rates

CDC STD Surveillance, 2006

were more prevalent in Hispanic/Latina women than they were in men (see Fig. 1)(1).

Between 2002 and 2006, the rate for primary and secondary syphilis increased among all racial and ethnic groups. Between 2005 and 2006, the rate of primary and secondary syphilis for Hispanics increased by 12.5%. In 2006, 15.8% of all primary and secondary syphilis cases in the U.S. reported to the CDC were Hispanics which was 1.9 times higher than it was for non-Hispanic whites (see Fig. 3):

Fig. 3 Syphilis - Rates by Race/Ethnicity and Sex: U.S., 2006
Fig-3 Syphilis Rate

CDC STD Surveillance, 2006

The prevalence of infection was much more pronounced in Hispanic men than it was for women. In 2006, the rate of congenital syphilis was 15.4 cases per 100,000 live births among Hispanics compared to 1.6 cases per 100,000 live births among non-Hispanic whites (1).

Risk Factors and STI

Migration has been identified as an independent risk factor in the incidence of STIs (3). The connection between Latino migrant labor and the spread of STIs/HIV has become the focus of increased research attention. Studies have attributed infection risks to multiple factors including behavior, sociodemographic, and environmental (3,4) - see Table 1:

Safer sex practices by migrant laborers are affected by traditional cultural beliefs and attitudes regarding gender roles, sexual behaviors, and condom use. There are common and yet dangerous misconceptions about STIs due to lack of education. Some do not know about health services that are available to them (including free condoms) within the community that they are working in. And even if they do take advantage of the health services available to them within a community, the lack of bilingual personnel hinder the effectiveness of prevention strategies to prevent STIs (4).

In addition, the community environment in which these workers reside during the harvest season can be filled with a multitude of risks. These can include the prevalence of alcohol, drugs and prostitution. The continuous flow of mostly male migrant laborers are more likely to encourage each other to participate in risky behaviors due to their separation from families and spouses. Sexworkers and drug suppliers who sell their services and products to farmworkers often travel from state to state, or remain stationed locally and make contact with each new group of farmworkers that passes through their area. While the majority of sexworkers are young Latinas, there are also American and Caribbean sexworkers that interact with the migrant farmworkers (3).

Most migrants have heard about STIs and HIV and know that they can get tested and treated for them. They also know that STIs/HIV can be transmitted via sexual contact, blood transfusions, and sharing of contaminated needles. Yet, many are not fully cognizant of the seriousness of the infections and view STIs as a nuisance. Common misconceptions include the belief that HIV can be transmitted through kissing, saliva, hugging, or contaminated clothing; that it is possible to tell if someone has an STI or HIV/AIDS simply by looking at them; that there is curative treatment for AIDS; and that sex with virgins should be sought.

While studies have shown that migrant laborers know that condoms can protect people from STI/HIV infection, their actual condom practices do not imply a solid grasp of their protective benefits. For example, women seem to seek out condom use after having several children as a form of birth control rather than to protect themselves from disease. On the other hand, men often have unprotected sex because they do not like condoms, or because they do not believe they are at risk, and sometimes even pay extra to avoid using them.

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Latinas should actively seek out providers who offer culturally and linguistically appropriate services. Research has shown that interventions aimed at reducing the prevalence of STIs among women of color are more likely to be effective if they are culturally relevant. Overcoming cultural and language barriers between patients and providers will increase the identification of STIs, increase accurate diagnosis and treatment, and ensure patient followup. Twenty-six percent of Latino adults are Spanish language dominant and need an interpreter when obtaining health care services. The delivery of linguistically appropriate health care services can positively influence health outcomes.

Latinas should be encouraged, and in some cases, be given the permission, to ask questions. They should be encouraged to get tested, and in turn, health care providers should "demystify" what testing is and what it is not. Health care providers need to understand and appreciate that talking about sex, sexual practices and infections can be taboo in some families and communities. Latinas may be too embarrassed to be open and forthcoming with their providers. This may especially be true with native-born Latinas and 1st generation Latinas. As a result, health care providers must exercise caution and not assume that all Latinas behave in this way. Research has demonstrated that the more acculturated Latina generation is indeed more open and are more desirous of these types of conversations with their health care providers. For example, the Office of Minority Health (5) showed that from 1991 to 2001, among Latina adolescents ages 15 to 17 years old, the proportion reporting reliance on no method of contraception fell from 33% to 20% across the decade while the proportion reporting the use of condoms rose from 28% to 45%. The proportion of young Latinas reporting the use of both birth control pills and condoms rose 16-fold. In 2003, 52% of sexually-active Latina adolescents reported the use of condoms during most recent sex. Overall, Latinas should be encouraged to attain as much information about their health. They also need to know that there are many community-based clinics and Planned Parenthood clinics that offer STI testing at no cost or on a sliding scale fee. In addition, Latinas need to know that they can request to be evaluated by a female health care provider if preferred.

Latino men also need to know this same information. Health care providers need to recognize that it is common practice for Latino men to seek medical advice for STIs, however, they may present with another chief complaint that has nothing to do with their STI due to the embarassment that they feel. An encounter that welcomes and respects all questions will have a greater impact for future health care provision for these Latino men. Health care providers also need to recognize that Latino men may not seek medical care in fear of being deported. One major topic for discussion is the demystification of the use of condoms in Latino men. It is important for all health care providers to ask about their condom practice and beliefs, and to educate them regarding the prevention of STIs.

Each state can improve the status of reproductive health for all Latinos by advocating for comprehensive sex education in schools and communities. Sex education is essential, considering that 46% of 9-12th grade Latinas have had sex compared to 43% of non-Hispanic white adolescent girls (5). Many teens want to receive comprehensive sex education, but are denied the opportunity because of policies favoring abstinence-only education in schools. Currently, only 20 states require schools to provide sexuality education and of those, only ten require that schools provide information about contraception. Abstinence-only programs fail to reach many sexually active adolescents who are at risk for acquiring an STI and/or becoming pregnant. Latinas can become health advocates and demand that their school systems provide comprehensive sex education so that they can be well-informed about contraception, STIs, and HIV prevention.

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